Provider Demographics
NPI:1538293790
Name:SOUTHPARK INTERNAL MEDICINE PC
Entity Type:Organization
Organization Name:SOUTHPARK INTERNAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:BURKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-266-6900
Mailing Address - Street 1:9088 RIDGELINE BLVD
Mailing Address - Street 2:STE 201
Mailing Address - City:HIGHLANDS RANCH
Mailing Address - State:CO
Mailing Address - Zip Code:80129-2383
Mailing Address - Country:US
Mailing Address - Phone:720-266-6900
Mailing Address - Fax:303-791-9920
Practice Address - Street 1:9088 RIDGELINE BLVD
Practice Address - Street 2:STE 201
Practice Address - City:HIGHLANDS RANCH
Practice Address - State:CO
Practice Address - Zip Code:80129-2383
Practice Address - Country:US
Practice Address - Phone:720-266-6900
Practice Address - Fax:303-791-9920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO29558207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CC4108Medicare PIN